Provider Demographics
NPI:1396088209
Name:DOHERTY, JOSEPH EDWARD (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:EDWARD
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:C/O DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5570
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:C/O DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-2663207P00000X
MS240342086S0102X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03837264Medicaid
MS488113YWZ1Medicare PIN